DENGUE

Etiology Dengue virus (4 serotypes;

flaviviruses)*
Epidemiologic Occurs in tropics and subtropics;
Factors transmitted by mosquito (Aedes
aegypti & albopictus); Residence in
or travel to endemic areas, other
virus exposure
Clinical Headache, musculoskeletal pain
Syndrome (“breakbone fever”); leukopenia;
occasionally biphasic
(“saddleback”) Fever
EPIDEMIOLOGY
• most common arboviral disease worldwide
• more than half a million cases of DHF occur each
year, with at least 12,000 deaths.
• patients have a triad of symptoms: hemorrhagic
manifestations, evidence of plasma leakage, and
platelet counts of <100,000/μl.
• mortality rates are 10–20%.
• dengue shock syndrome: mortality rates can reach 40%
• supportive care to maintain blood pressure and
intravascular volume with careful volume-
replacement therapy is key to survival.
CASE DEFINITION
DENGUE FEVER DENGUE W/O WARNING SIGNS
(OLD) (NEW)
Probable dengue: Probable dengue:
An acute febrile illness with 2 or Lives in or travels to dengue-
more of the following: endemic area, with fever,
• Headache plus any two of the following:
• Retro-orbital pain • Headache
• Arthralgia • Body malaise
• Rash • Myalgia
• Hemorrhagic manifestations • Arthralgia
• Leukopenia; • Retro-orbital pain
AND • Anorexia
• Supportive serology (a • Nausea
reciprocal HI antibody titer • Vomiting
>1280, a comparable IgG assay • Diarrhea
ELISA titer or • Flushed skin
(+) IgM antibody test on a late • Rash (petechial, Hermann’s
or acute convalescent phase sign)
serum specimen AND
CASE DEFINITION
DENGUE FEVER DENGUE W/O WARNING SIGNS
(OLD) (NEW)
Confirmed: AND
A case confirmed by laboratory • Laboratory test, at least CBC
criteria (leucopenia with or
without thrombocytopenia)
and/or dengue NS1 antigen
test or dengue IgM antibody
test (optional)

Confirmed dengue:
• Viral culture isolation
• PCR
CASE DEFINITION
DENGUE HEMORRHAGIC FEVER
(OLD)
The following must all be
present:
1. Fever, or history of fever,
lasting for 2-7 days,
occasionally biphasic
2. Hemorrhagic tendencies
evidenced by at least one
of the following:
a. (+) tourniquet test
b. Petechia, ecchymosis,
purpura
c. Bleeding from the mucosa,
GIT, injection sites
or other locations
d. Hematemesis or melena
3. Thrombocytopenia (100,000
cells/mm3 or less)
DENGUE W/ WARNING SIGNS
(NEW)
Lives in or travels to dengue-
endemic area, with fever
lasting for 2-7 days, plus any of
the following:
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical signs of fluid
accumulation
• Mucosal bleeding
• Lethargy, restlessness
• Liver enlargement
• Laboratory: increase in Hct
and/or decreasing platelet
count
CASE DEFINITION
DENGUE HEMORRHAGIC FEVER DENGUE W/ WARNING SIGNS
(OLD) (NEW)
4. Evidence of plasma leakage Confirmed dengue:
due to increased • Viral culture isolation
vascular permeability, • PCR
manifested by at least one
of the following:
a. A rise in the hematocrit equal
to or greater than
20% above average for age,
sex, and population
b. A drop in the hematocrit
following volume replacement
treatment equal to or greater
than
20% of baseline
c. Signs of plasma leakage such
as pleural effusion,
ascites and hypoproteinemia
CASE DEFINITION
DENGUE SHOCK SYNDROME
(OLD)
All of the four criteria for DHF
must be present plus evidence
of circulatory failure manifested
by:
• Rapid and weak pulse, AND
• Narrow pulse pressure (<20
mmHg [2.7kPa])
OR
manifested by:
• Hypotension for age, AND
• Cold clammy skin and
restlessness
SEVERE DENGUE
(NEW)
Lives in or travels to a dengue-
endemic area with fever of 2-7
days and any of the above
clinical manifestations for
dengue with or without warning
signs, plus any of the following:
• Severe plasma leakage,
leading to:
- Shock
- Fluid accumulation with
respiratory distress
• Severe bleeding
• Severe organ impairment
- Liver: AST or ALT >1000
- CNS: e.g., impaired
consciousness
- Heart: e.g., myocarditis
- Kidneys e.g., renal failure
COURSE OF ILLNESS
MEDICAL COMPLICATIONS
FEBRILE CRITICAL RECOVERY
Dehydration Shock from plasma Hypervolemia (only if
leakage intravenous fluid
High fever may therapy has been
cause neurological Severe haemorrhage excessive and/or has
disturbances and extended into this
febrile seizures in Organ impairment period)
young children
Acute pulmonary
edema
AGGRAVATING/RISK FACTORS:
• presence or absence of enhancing and non-neutralizing
antibodies
• age (below 12 years of age)
• sex (females are more often affected than males)
• race (whites are more often affected than blacks)
• nutritional status (good nutrition)
• sequence of infections (e.g., dengue virus 1  dengue virus
2 infection more dangerous vs dengue virus 4  dengue
virus 2)
• considerable heterogeneity exists among each dengue
virus population, i.e., southeast asian dengue virus 2 variants
have more potential to cause severe dengue than do other
variants
ASSESSMENT
• History (onset, intake/output)
OVERALL • PE (GCS, hydration, rash,
TORNIQUET TEST)
• Investigation (CBC)

• Febrile/critical/recovery
DIAGNOSIS
• Warning signs?
(Phase &
Severity) • Hydration & hemodynamic
status?

• Disease notification
MANAGEMENT
• Decisions
TREATMENT
A B C
Should be referred for Require emergency
May be sent home in-hospital treatment and
management urgent referral
• Able to tolerate • With warning signs • With severe
adequate volumes • With co-existing dengue
of oral fluids conditions, e.g. (i) plasma
• Pass urine at least pregnancy, leakage that may
once every 6 hours infancy and old lead to shock
• Do not have any age, obesity, DM, (dengue shock)
warning signs, renal failure, and/or fluid
particularly when chronic hemolytic accumulation, with
fever subsides diseases, etc. or without respiratory
• Social distress, and/or
circumstances (ii) severe bleeding,
such as living and/or
alone or living far (iii) severe organ
or without a Impairment
reliable means of
transport
TREATMENT- GROUP A
GROUP A – MAY BE SENT HOME
• oral rehydration solutions

• reduce osmolarity of ors containing sodium 45 to 60 mmol/liter.

• sports drinks should not be given due to its high osmolarity which
may cause more danger to the patient.
TREATMENT

GROUP A – MAY BE SENT HOME

TREATMENT- GROUP B
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL
MANAGEMENT
DENGUE WITHOUT WARNING SIGNS
• encourage oral fluids. if not tolerated, start intravenous fluid
therapy of 0.9% nacl (saline) or ringer’s lactate with or
without dextrose at maintenance rate
• patients may be able to take oral fluids after a few hours of
intravenous fluid therapy.
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL
MANAGEMENT
DENGUE WITHOUT WARNING SIGNS
• isotonic solutions (D5 LRS, D5 ACETATED RINGERS D5 NSS/D5
0.9 NACL) are appropriate for dengue patients without
warning signs who are admitted without shock.
• maintenance IVF is computed using the caloric expenditure
method (holliday-segar method) or calculation based on
weight (ludan method).
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL MANAGEMENT (DENGUE
WITHOUT WARNING SIGNS)
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL MANAGEMENT
(DENGUE WITHOUT WARNING SIGNS)

• if the patient shows signs of mild dehydration but is not in shock, the
volume needed for mild dehydration is added to the maintenance
fluids to determine the total fluid requirement (tfr).
• the following formula may be used to calculate the required volume
of intravenous fluid to infuse:
TFR = MAINTENANCE IVF + FLUIDS AS FOR MILD DEHYDRATION*

where the volume of fluids for mild dehydration is computed

as follows: infant 50 ml/kg
older child or adult 30 ml/kg
• one-half of the computed TFR is given in 8 hours and the remaining
one-half is given in the next 16 hours
SAMPLE COMPUTATION FOR A 10 KG PATIENT WITH DENGUE AND MILD
DEHYDRATION:

STEP 1 : COMPUTE FOR TOTAL FLUID REQUIREMENT:

TFR = MAINTENANCE FLUIDS + FLUIDS FOR MILD
DEHYDRATION
= (100 X 10 KG) + (50 X 10 KG) = 1000 + 500 = 1500 ML

STEP 2 : COMPUTE ONE-HALF OF TFR:

TFR/2 = 1500 ML/2 = 750 ML
STEP 3 : VOLUME TO BE GIVEN IN THE FIRST 8 HOURS:
= 750 ML IN 8 HOURS = 93 ML/HOUR FOR 8 HOURS
STEP 4 : VOLUME TO BE GIVEN IN THE NEXT 16 HOURS:
= 750 ML IN 16 HOURS = 46 ML PER HOUR FOR 16 HOURS
TREATMENT
GROUP B – (DENGUE WITHOUT WARNING SIGNS)
• periodic assessment is needed so that fluid may be adjusted
accordingly

• clinical parameters should be monitored closely and correlated with

the hematocrit. this will ensure adequate rehydration, avoiding under
and over hydration.
• the ivf rate may be decreased anytime as necessary based on clinical
assessment.
• if the patient shows signs of deterioration see management for
compensated or hypotensive shock, whichever is applicable.
TREATMENT
GROUP B (DENGUE WITHOUT WARNING SIGNS)

MONITORING BY HEALTH CARE PROVIDERS:

• temperature pattern
• volume of fluid intake and losses
• urine output – volume and frequency
• warning signs
• hematocrit, white blood cell and platelet counts
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL MANAGEMENT
(DENGUE WITH WARNING SIGNS)

1. obtain a reference hematocrit before fluid therapy

2. give only isotonic solutions such as 0.9% nacl (saline), ringer’s
lactate
• start with 5-7 ml/kg/hour for 1-2 hours, then
• reduce to 3-5 ml/kg/hr for 2-4 hours, and then
• reduce to 2-3 ml/kg/hr or less according to clinical response
3. reassess the clinical status and repeat the hematocrit
4. if the hematocrit remains the same or rises only minimally,
continue with the same rate (2-3 ml/kg/hr) for another 2-4 hours.
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL MANAGEMENT
(DENGUE WITH WARNING SIGNS)
5. if there are worsening of vital signs and rapidly rising hematocrit, increase
the rate to 5-10 ml/kg/hour for 1-2 hours
6. reassess the clinical status, repeat hematocrit and review fluid infusion rates
accordingly
7. give the minimum intravenous fluid volume required to maintain good
perfusion and urine output of about 0.5 ml/kg/hr. intravenous fluids are usually
needed for only 24 to 48 hours.
8. reduce intravenous fluids gradually when the rate of plasma leakage
decreases towards the end of the critical phase. this is indicated by:
• urine output and/or oral fluid intake is/are adequate, or
• hematocrit decreases below the baseline value in a stable patient
TREATMENT
GROUP B – SHOULD BE REFERRED FOR IN-HOSPITAL MANAGEMENT
(DENGUE WITH WARNING SIGNS)
MONITORING BY HEALTH CARE PROVIDERS:
• Patients with warning signs should be monitored until the “at-risk”
period is over. A detailed fluid balance should be maintained.
• parameters that should be monitored include:
• vital signs and peripheral perfusion (1-4 hourly until the patient is out
of critical phase)
• urine output (4-6 hourly)
• hematocrit (before and after fluid replacement, then 6-12 hourly)
• blood glucose
• other organ functions (such as renal profile, liver profile, coagulation
profile, as indicated)
TREATMENT
GROUP C – PATIENTS WITH SEVERE DENGUE REQUIRING EMERGENCY
TREATMENT AND URGENT REFERRAL

MANAGEMENT FOR PATIENTS ADMITTED TO THE HOSPITAL WITH

COMPENSATED SHOCK
1. Start intravenous fluid resuscitation with isotonic crystalloid solutions at 5-
10 ml/kg/hr over 1 hour, then reassess the patients condition (vital signs,
capillary refill time, hematocrit, urine output) and decide depending on the
situation:
2. If the patients condition improves, intravenous fluids should be gradually
reduced to
• 5-7 ml/kg/hr for 1-2 hours, then
• To 3-5 ml/kg/hr for 2-4 hours, then
• To 2-3 ml/kg/hr and then

• To reduce further depending on hemodynamic status, which can be

maintained for up to 24 to 48 hours
 TREATMENT
GROUP C – PATIENTS WITH SEVERE DENGUE REQUIRING EMERGENCY TREATMENT
AND URGENT REFERRAL

MANAGEMENT FOR PATIENTS ADMITTED TO THE HOSPITAL WITH COMPENSATED

SHOCK
3. If vital signs are still unstable (shock persists), check the hematocrit after the
first bolus:
• If hematocrit increases or is still high (>50%), repeat a second bolus of
crystalloid solution at 10-20 ml/kg/hr for 1 hour.
• After this second bolus, if there is improvement, then reduce the rate to 7-10
ml/kg/hr for 1-2 hours, and then continue to reduce as above
• If hematocrit decreases compared to the initial reference hematocrit (<40%
in children and adult females, <45% in adult males), this indicates bleeding
and the need to cross-match and transfuse blood as soon as possible
4. Further boluses of crystalloid or colloidal solutions may need to be given
during the next 24 to 48 hours
TREATMENT
MANAGEMENT FOR PATIENTS ADMITTED TO THE HOSPITAL WITH
HYPOTENSIVE SHOCK
Patients with hypotensive shock should be managed more
vigorously
1. Initiate intravenous fluid resuscitation with crystalloid or colloid
solution (if available) at 20 ml/kg as a bolus given over 15 minutes
to bring the patient out of shock as quickly as possible.
2. If the patient’s condition improves, give a crystalloid/colloid
infusion of 10 ml/kg/hr for 1 hour, then continue with crystalloid
infusion and gradually reduce
• To 5-7 ml/kg/hr for 1-2 hours, then
• To 3-5 ml/kg/hr for 2-4 hours and then
• To 2-3 ml/kg/hr or less, which can be maintained for up to 24 to 48
hours
 TREATMENT
GROUP C – PATIENTS WITH SEVERE DENGUE REQUIRING EMERGENCY TREATMENT AND
URGENT REFERRAL
3. If vital signs are still unstable (shock persists), check hematocrit after the first
bolus:
• If hematocrit increases compared to the previous value or remains very high
(>50%), change intravenous fluids to colloid solutions at 10-20 ml/kg as a second
bolus over ½ to 1 hour. After this dose, reduce the rate to 7-10 ml/kg/hr for 1-2
hours, then change back to crystalloid solution and reduce rate of infusion as
mentioned above when the patient’s condition improves
• If hematocrit decreases compared to the previous value (<40% in children and
adult females, <45% in adult males), this indicates bleeding and the need to cross-
match and transfuse blood as soon as possible
4. Further boluses of fluid may need to be given during the next 24 hours. The rate
and volume of each bolus infusion should be titrated to the clinical response.
Patients with severe dengue should be admitted to the high dependency or
intensive care areas.
 TREATMENT
GROUP C – PATIENTS WITH SEVERE DENGUE REQUIRING EMERGENCY
TREATMENT AND URGENT REFERRAL

MONITORING
• Patients with dengue shock should be frequently monitored, until the
danger period is over. A detailed fluid balance of all input and
output should be maintained.
Interpretation of hematocrit: changes in the hematocrit are a useful
guide to treatment. However, it must be interpreted in parallel to the
hemodynamic status, the clinical response to fluid therapy and the
acid-base balance.
TREATMENT
For example: A rising or persistently high hematocrit:
• Together with unstable vital signs (particularly narrowing of the pulse
pressure) indicates active plasma leakage and the need for a further
bolus of fluid replacement.
• With stable hemodynamic status and adequate urine output, do not
require extra intravenous fluid. Continue to monitor closely and it is likely
that the hematocrit will start to fall within the next 24 hours as the plasma
leakage stops
For example: a decrease in hematocrit:
• Together with unstable vital signs (particularly narrowing of the pulse
pressure, tachycardia, metabolic acidosis, poor urine output) indicates
major hemorrhage and the need for urgent blood transfusion
• Together with stable hemodynamic status and adequate urine output
indicates hemodilution and/or re-absorption of extravasated fluids;
intravenous fluids
• Must be discontinued immediately to avoid pulmonary edema
TREATMENT
DISCHARGE CRITERIA
1. No fever for 48 hours
2. Improvement in clinical status (general well-being,
appetite, hemodynamic status, urine output, no respiratory
distress)
3. Minimum of 2-3d have elapsed after recovery from shock
3. Increasing trend of platelet count
4. Stable hematocrit without intravenous fluids
SUMMARY
SUMMARY
SUMMARY
DENGVAXIA

“The only way to eradicate dengue as a public health

problem is a safe, broadly protective, effective dengue
vaccine side by side with vector control.”